Friday, January 15, 2010

Where Were the Techs and Nurses?

Medicine is a team sport. No single doctor can do what they do without tons of help from nurses, technicians, clerical staff, and yes, even adminstrators.

So it was with considerable surprise that I saw this piece from the Baltimore Sun:

"An internal review, begun last May at the behest of federal investigators and in response to a patient complaint, has turned up 369 patients with stents that appear to have been implanted in their arteries unnecessarily, CEO Jeffrey K. Norman said in an interview yesterday. Patients began receiving letters alerting them to the finding early last month, and more notifications are expected as the review continues.

"We take our interaction and the care of our patients with the utmost seriousness, and so we wanted to alert patients and their physicians to what we found," said Norman.

In several cases reviewed by The Baltimore Sun, patients who received coronary stents at St. Joseph - purportedly to open a clogged artery to correct a severe blockage - have since learned they had only minor blockage, if any. One 69-year-old man was told his artery had a 95 percent blockage, yet the new review suggests something closer to 10 percent, which is considered insignificant. A 55-year-old woman who agreed to receive a stent after being told she had a 90 percent blockage has since learned she had virtually no problem and that she never suffered from the heart diagnosis that has consumed her life for the past 18 months."

As bad as this might seem, realize that during angiogram procedures there are technicians and nurses that are responsible for prepping the room, administering meds and monitoring the patient. No physician works in isolation and everyone can see the monitors. Face it, the difference between a 95% blockage and a 10% blockage in a coronary artery is not subtle.

So, yes, the doctor's actions in this case are unconscionable and should be met with swift action, but when something like this is allowed to occur it's much more than the fault of a single doctor.

6 comments:

ChicagoPA
said...

Love the blog, really I do. And I also am a strong proponent of analyzing hospitals from a systems perspective to reduce error and improve patient safety.

But let's be honest, what is the outcome when a "lowly tech" questions the judgement of a "board certified, MD, PhD-been doin' this since before you were born" cardiologist? The tech is berated for their insolence, as who are they to question the physicians judgement?

Changing hospital systems starts and ends with physician leadership, and until that emerges the ax will continue to fall on those with the most initials after their name.

Changing hospital systems starts and ends with physician leadership, and until that emerges the ax will continue to fall on those with the most initials after their name.

I have no problem with the ax falling on those ultimately responsible. But remember its about the patient. Hundreds of caths with similar results should never have been tolerated by support staff who know better. The attitude where techs are viewed as "lowly" and are subject to retribution when questions are raised is part of the problem, and the fact that there might be no recourse options (or awareness of such programs) available to staff when doctors don't perform ethically is another. Ego's aside, no patient care team should forget it's about the patient. Ever.

I am an RN in Cath Lab. While I agree that the offending doc might brush aside any concerns raised about his practice, there are other physicians and avenues that can be used to voice concerns. Our Medical Directors in the Cath Lab have always been open to questions and concerns from the staff, our Cath Lab Manager and Director are available, and failing all of that we have a Quality Management Department that will take concerns that the staff has to the Hospital's Physician leadership. I agree w/ Dr Wes that we all have an obligation to be an advocate for the patients. Every patient, every time.

While I can relate to the comments of ChicagoPA, it was drilled into me during nursing school that my number one job was "patient advocate", and that required me to speak up when I saw something I thought was wrong - even if it was a superior doing it.

If I saw THIS happening and knew it was wrong, I would definitely speak up. And if I got attitude from that physician, I would alert the higher ups.

I do believe it is a systemic problem. If the staff really did know what was going on, and failed to respond, I believe they are guilty as well.

This is actually alarming and maybe the tip of the iceberg in SOME places/hospitals. I believe nurses and techs can help avert such situations. Maybe they should have some sort of backup to avoid this in th cath lab. Can other staff see the lesion size when this happens?

In this day and age, the role of angiography alone is truly not enough to determine functional stenosis of a lesion. FFR and IVUS is widely available and for questionable lesions or morphology, the cardiologist should always consider its use. Not using it in regularity is approaching malpractice in my opinion.

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.